Nursing Elites

1. A client with asthma develops respiratory acidosis. Based on this diagnosis, what should the nurse expect the client's serum potassium level to be?

• A. normal
• B. elevated
• C. low
• D. unrelated to the pH

Correct answer: B

Rationale: In respiratory acidosis, the body retains CO2, leading to increased hydrogen ion concentration and a drop in blood pH. As pH decreases, serum potassium levels increase due to the movement of potassium out of cells to compensate for the acidosis. Elevated serum potassium levels are expected in respiratory acidosis. Choice A ('normal') is incorrect because potassium levels are expected to be elevated in respiratory acidosis. Choice C ('low') is incorrect as potassium levels rise in this condition. Choice D ('unrelated to the pH') is incorrect as serum potassium levels are directly impacted by changes in pH in respiratory acidosis.

2. A violation of a patient's confidentiality occurs if two nurses are discussing client information in which of the following scenarios?

• A. With a physical therapist treating the patient
• B. With a social worker planning for discharge
• C. With another nurse on duty to plan for break time
• D. In the hallway outside the patient's room

Correct answer: D

Rationale: The correct answer is 'In the hallway outside the patient's room.' Discussing client information in a public area like a hallway can potentially breach patient confidentiality as it increases the risk of unauthorized individuals overhearing sensitive information. Choices A, B, and C involve discussing client information with other healthcare professionals in appropriate settings, which are more likely to maintain patient confidentiality compared to discussing in a public space like a hallway. Option D is the correct choice because it highlights a scenario where patient information is at higher risk of exposure to unauthorized individuals, hence violating patient confidentiality.

3. Which of the following is an inappropriate item to include in planning care for a severely neutropenic client?

• A. Transfuse neutrophils (granulocytes) to prevent infection.
• B. Exclude raw vegetables from the diet.
• C. Avoid administering rectal suppositories.
• D. Prohibit vases of fresh flowers and plants in the client's room.

Correct answer: A

Rationale: The correct answer is to transfuse neutrophils (granulocytes) to prevent infection. Granulocyte transfusion is not routinely indicated to prevent infection in neutropenic clients. While neutrophils are essential in fighting infections and are beneficial in selected populations of infected, severely granulocytopenic clients who do not respond to antibiotics and are expected to experience prolonged suppression of granulocyte production, routine granulocyte transfusion is not recommended. Choices B, C, and D are appropriate interventions for a severely neutropenic client. Prohibiting fresh flowers and plants helps reduce the risk of exposure to environmental pathogens. Avoiding rectal suppositories minimizes the risk of introducing harmful bacteria. Excluding raw vegetables from the diet reduces the likelihood of foodborne infections.

4. Which of the following infant behaviors demonstrates the concept of object permanence?

• A. The infant cries when his mother leaves the room.
• B. The infant looks at the floor to find a toy that he was playing with and dropped.
• C. The infant picks up another toy after the one he was playing with rolls under the couch.
• D. The infant participates in a game of patty-cake.

Correct answer: B

Rationale: Object permanence occurs when the infant learns that something or someone still exists even though they might not be able to see it or them. This typically develops between 9 and 10 months of age. The correct answer, 'The infant looks at the floor to find a toy that he was playing with and dropped,' demonstrates object permanence as the infant understands that the toy still exists even though it is temporarily out of sight. Choices A and C do not directly relate to object permanence as the behaviors described do not necessarily indicate an understanding of objects existing when out of sight. Choice D is incorrect as participating in a game of patty-cake does not involve demonstrating object permanence. Peek-a-boo is a more suitable example of a game that demonstrates object permanence, as the infant continues to look for the hidden face, understanding that it still exists even though temporarily unseen.

5. Which of the following is not a primary function of the kidneys?

• A. blood pressure control
• B. vitamin D activation
• C. erythropoietin production
• D. reabsorption of waste products

Correct answer: D

Rationale: The correct answer is reabsorption of waste products because the kidneys excrete waste products rather than reabsorbing them. Choices A, B, and C are indeed primary functions of the kidneys. The kidneys play a crucial role in regulating blood pressure, activating vitamin D, and producing erythropoietin, which stimulates red blood cell production. Therefore, the primary role of the kidneys is to filter blood, remove waste products, regulate fluid balance, and maintain electrolyte balance.

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